Data Quality Management Control Program (DQMC)

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

1

Data Quality Management Control Program (DQMC)

AFMS Data Quality ProgramAFMSA/SGY


Overview

Data Quality (DQ) ProgramSystemsDQ Composite Health Care System (CHCS)

InitiativesFY10 UpdatesTake AwayQuestions


DQMC Program

Data Quality Manager

Data Quality Assurance Team

DQMC Review List

Data Quality Statement

INSTRUCTION

Department of Defense

DODI 6040.40Military Health System

Data Quality Management Control Procedures


DQ Team Roles and Responsibilities

Team Key Players DQ Manager Resource Management Office (RMO) Group Practice Manager (GPM) Medical Expense and Performance Reporting System (MEPRS) Credentials Manager Budget Analyst/Uniform Business Office (UBO) Coding/Billing Supervisor Clinical Systems Administrator(s)

It is great to look – But are you working toward improvement?


DQ Team Roles and Responsibilities

DQ team meets monthly

Review Metrics/Compliance Issues Provide deficiency correction plan and estimated

completion date (if applicable) Report monthly to Executive Committee Keep meeting minutes for at least two years Keep Review Lists for five years

It is great to look – But are you working toward improvement?


DQ Team Responsibilities Cont…

DQMC Review List Maintained locally Tool to assist Military Treatment Facilities (MTFs) in

identifying and correcting financial and clinical workload data problems monthly

Data Quality Statement Facility Report Card Specific information from the DQMC Review List Commander signs/approves monthly Forwarded through the regional office to AF DQ

Manager AF summary submitted to DQMC


Air Force

DQ System Architecture

MDRMDR

M2M2

WWR(Count Visits)

EAS IVEAS IV“Eligible” Encounters

CPT Codes Units of Service

WAMWAMCount Visits & Raw Services

SADR(Encounters)

TPOCSTPOCSBillable

Encounters

PDTSPDTS

Worldwide Workload Report

Standard Ambulatory Data Record

EAS Repository

ADMExtract

MHS Data Repository

MHS Mart

Service Repository (BDQAS)

Pharmacy Data Transaction System

Pop HealthPortal

CCE

Coding Compliance Editor

ClinicalData Mart

TRICAREOps Center

DoD/VA SHARE

SADR 1/SADR 2


“E” – Support “D” – Ancillary “A” – Inpatient “B” – Outpatient “C” – Dental

+ “F” – Special Programs

+ “G” – Readiness

EAS IVMoney

Manpower

Workload

CRIS

EAS-SA

CHCS / WAM

(Count only)

RECONCILE

Direct Care “Step Down”

Medical Expense and Performance Reporting System“MEPRS” -- Valuation

Defense Health Program Cost Accounting

OUTPUT

TotalCost

RVUs RWPs

ICD/E&M/CPTDRGsSIDR

SADRCHCS


MHS Management Analysis and Reporting Tool (M2) Used to extract data for PPS and AF Business Plan Need to identify the M2 user and alternate in your

facility TMA WISDOM course

EASIV Repository MEPRS data

Cost per data 45 day processing period for current month

MEPRS Manager TMA MADI Course

DQ Monitoring Tools


MEPRS Early Warning and Control System (MEWACS) Trend analysis tool Usage monitored by DQMC Outlier indications

Review and correct data accordinglyOutliers are not always incorrect data

DQ Monitoring Tools Cont…


BDQAS Ambulatory and Inpatient Metrics

FY “Point-in-time" Comparison Reports Updated on the 20th of the month Display by MTF or MAJCOM

MTF Rankings, Transmission Reports (daily/summary), Top DRG, "Principal" Diagnosis and Procedure Reports, E&M by Provider Specialty

Data Quality Statement Reports Compare and report values on DQ statement Consistent reporting for questions: 1a, 2a-b,

4b-d, 8a-d, 9

DQ Monitoring Tools Cont…


BDQAS



BRAC Monitor efficiency of the healthcare system Performance Based Budgeting – PPS Medicare Accrual Fund MTF Business Plans Provider/Clinic Workload Productivity Determine Level of Effort by all clinic staff Reimbursements (TPC, Coast Guard, NOAA…etc) Enable the Leadership to make informed decisions

How is your data used?


Provider File

Civilian (Outside) Provider File Pharmacy/Lab/Rad are required to add the Civilian

Provider to CHCS. Is there a local policy? Create a local policy/standard operating procedure Educate and train the ancillary staff Use correct PSC linked to HIPAA Taxonomy

Provider naming convention, NPI, and DEA/License number should be strictly enforced and monitored Last Name/First Name, Middle Name or Initial (if available) Example: Smith / Johnson,S / Provider / Outside Provider Recommend subscribing to HCIdea to research

NPI/DEA/License # ; http://www.hcidea.org/


Provider Profiles (con’t)Incorrect fields in red:PROVIDER: SMITH, JOHN R Name: SMITH, JOHN RProvider Flag: PROVIDERProvider ID: Provider1234NPI Type/ID: Provider Class: DocPerson Identifier: 123-45-6789Person ID Type Code: Select PROVIDER SPECIALTY: 517 (DENTAL CONSULTANT)Primary Provider Taxonomy:CMAC Provider Class: -Select PROVIDER TAXONOMY:HCP SIDR-ID:Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: 123-45-6789 DEA#: 99999999License #:

Corrected fields in red:PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: PROVIDERProvider ID: SMITHJRNPI Type/ID: 01/0125899Provider Class: OUTSIDE PROVIDERPerson Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN)Primary Provider Taxonomy: 207Q00000XCMAC Provider Class: -Select PROVIDER TAXONOMY:HCP SIDR-ID:Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRSSSN: 123-45-6789 (Not Mandatory)DEA#: BM1212127 License #:


Pharmacy makes up 70 to 80% of your facilities collections

Average # Claims for Outside Provider Scripts per month Large Facility 1,500-3,000 Medium Facility 700 Small Facility 300

Average Amount Billed per claim: $50 If your provider file has 100 outside providers that issued

at least one script per month with missing data in their profile: provider specialty codes, NPI (new requirement mid FY08), DEA #, provider name and ID. Potential Loss is $5,000 in billable claims per month Potential Loss is $60,000 in billable claims per year

Potential Revenue Impact


Enter Provider Specialty Code (Be specific – not general) All PA’s – Provider Specialty Code 901 All Technicians – Provider Specialty Code 900 Independent Duty Medical Technician – Provider

Specialty Code 521 Lost revenue for codes 500 – 518 and 910 – 999

Zero workload RVU Prevent Encounter from flowing to TPOCS Impact on PPS

Provider Specialties 910 and above are Clinical Services

Provider Specialty Codes


Value of Care PEDIATRICS – BDA Provider Specialty Code = 040

Pediatrician Diagnosis Codes

204 Lymphoid Leukemia 112.89 Candidial Endocarditis

Procedure Code 90780 Intravenous infusion for

therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour

90781 – Each additional hour E&M Code

99214 – Level 4 Established Patient OHI – Yes CMAC Value = $130.73 Class 1 Provider Will you bill for this patient? Yes

Reimbursement - $130.73 PPS RVU = 1.44 Reimbursement = $106.56

PEDIATRICS – BDA Provider Specialty Code = 949

Pediatrics Diagnosis Codes

204 Lymphoid Leukemia 112.89 Candidial Endocarditis

Procedure Code 90780 Intravenous infusion for

therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour

90781 – Each additional hour E&M Code

99214 – Level 4 Established Patient OHI – Yes CMAC Value = UNKNOWN Will you bill for this patient? NO

Reimbursement $0 PPS Workload = ZERO!!!!!!ZERO!!!!!!


AF CHCS DQ Initiative

Contract awarded Sept 06 Hired 2 contractors Review and analyze CHCS File and Table Build

Provider FileProvide functional and technical guidanceProvider File Report Card (SAR replacement)

Establish CHCS DQ standardsProcess ownership of data elementsPolicies, business rules, and AFMS standardization

(CHCS DQ Continuity Guide, AFMOA Resolution Guide)


AFMS –CHCS Provider File % of Total Error/Discrepancy By Error Type- Jul 2009

Error-Discrepancy TOTAL %

NPI - NULL 276960 46%NPI - Duplicate 3027 0%Generic Provider 1543 0%Potential Duplicate 3328 1%Naming Convention 20749 3%DEA / License # 3705 1%SSN 0 0%Specialty Code (PSC) 14647 2%HIPAA Taxonomy 41143 7%Pclass MisMatch 2013 0%Primary Hospital Location 5364 1%Signature Class 3652 1%EDI-PN 0 0%

TOTAL 376131 62%

TOTAL RECORDS REVIEWED 605809


New and Improved ProcessProvider File Detail Data Base

Data Quality Contract Personnel developed the following approach Smartronix sub to PSI

Central DSS Provider File pull from each MTF CHCS Automated query identified potential errors/improvement

opportunities Results exported into an Access database

Produces a “Detail Report” for each facility Actionable listing of MTF specific entries requiring attention Enables MTF to use limited resources on problem resolution Drillable to focus efforts on recent activity

Generates a MTF “Provider File Report Card” Sample on next slide


Volume and error types will dictate cleanup

strategies

Peer Group Comparison


Provider Report Card(continued – page 2)

Monthly error rates for the MTF


New and Improved ProcessMTF Provider File Report Cards

MTF Report Cards Automatically generated from the MTF detail file Baseline MTF CHCS provider file metrics Shows types of errors/discrepancies Shows the primary effect/impact Focused two-page format More readable and actionable

Includes performance measures (peer-group based) Error rates for each MTF/DMIS captured Monthly trend analysis of new provider entries Other statistical information captured for future comparison

AFMOA DQ Follow-up ingrained in the process


CHCS Provider FileRoles and Responsibilities

AFMOA SGAR/Data

Quality ProgramOffice

MTFDQ

Team

Provide analysisfor the MTF

Guide MTF through data clean-up

Action plan for clean-up

Report data at DQMC

Provide feedback to AFMOA/DQ

Indentify training issuesFacilitate

training

Conduct site visits asneeded

Share data with proper DQ teammates

Provide performancemeasures

Help MTFs focus efforts

Provide MTFs recommended processes/ share best practices

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 27

Way Ahead

27

Way Ahead

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Baseline -All active providers

Baseline

(10Aug-Rpt Card)

FY10- 2nd Qtr

(15 Oct-Rpt Card)

FY 10 2nd Qtr

(15 Jan- Rpt Card)

FY 10 3rd Qtr

(15 Apr- Rpt Card)

Order Entry activity to focus on recent activity(conceptual report on next slide)

Match w/OHI information

Annual review

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 28

Conceptual report that will show MTFs potential $ lost Reflects providers with

NULL provider NPIs, not the rest of the errors

Reflects current primary insurance listed in CHCS

Opportunity to show the MTFs “What’s in it for them”

28

Way Ahead - Conceptual Report“Potential” Impact to TPC


DQ Tool Kit

Data Quality Statement Guide Reporting Consistency Training document for new personnel

AFMOA Resolution Guide – How to guide produced to assist MTF’s in the provider data cleanup process

CHCS DQ Continuity Guide, Version 2 CHCS Standardized Business Rules

AFMS Workload Guidelines Version 2.0 (draft) Brings together DQ, MEPRS, Coding and Billing AF supplemental guidance to DOD coding

guidelines


Sample of Continuity Guide

Data Element Description AF DQ Standards

National Provider Identifier (NPI)

10-Digit number for electronic billing

For any provider flagged as “Provider” these files require an NPI number. If services are rendered by a provider containing no NPI, it will prevent claims to be paid for patients with Third Party Insurance

Provider File Standards and Business Rules


Sample of Workload Guidelines

Encounter Activity

Provider Type

Provider Specialty

Code

MEPRS Code for

Time Capture

MEPRS Code for

Workload

Count/Non-Count

indicator

Patient Encounter Business Rules

Coding Required

Billing Required

Nutritionist/Dietitian

Privileged Provider

704 - Dietician/ Nutritionist

B*** B*** Count Registered dieticians or licensed nutrition Professionals are responsible for providing medical nutrition therapy (MNT).

Yes Yes


DQ Web Page

Contact:

Darrell Dorrian, InterimAir Force Data Quality Program Manager

Tel (703) 681-6504 DSN 761Fax (703) 681-6011 DSN 761

https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DataQuality

Documents, briefings, policies/directives, training

and links



Data Quality StatementCompleteness

Question 1. In the reporting month (include only B*** and FBN* accounts):

a) What percentage of clinics have complied with “End of Day” processing requirements, “Every clinic – Every day?” (B.5.(a))

Question 1a is deleted for FY10.


Data Quality StatementCompleteness

Question 1. In the reporting month (include only B*** and FBN* accounts): 1b becomes 1a

a) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.(b)) Source is BDQAS

Number of closed appointments

Total appointments for the month


Data Quality StatementTimeliness

Question 2. In accordance with legal and medical coding practices, have all of the following occurred:

a) What percentage of Outpatient Encounters, other than APVs, has been coded within 3 business days of the encounter? Source is BDQAS

b) What percentage of APVs have been coded within 15 days of the encounter? Source is BDQAS

c) What percentage of Inpatient records have been coded within 30 days after discharge? Internal Process - CCE Report (Un-coded records report)


Question 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual), DoD 6010.13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation. a) Was monthly MEPRS/EAS financial reconciliation

process completed, validated and approved prior to monthly MEPRS transmission? Source is MEPRS Manager and RMO Office

b) Were the data load status, outlier/variance, WWR-EAS IV, and allocations tabs in the current MEWACS document reviewed and explanations provided for flagged data anomalies? Source is MEPRS Manager

Data Quality StatementValidation and Reconciliation


Question 3. Continued…New Questions on Timecards submitted by Service determined date. c) For DMHRSi, what is the percentage of submitted

timecards by the suspense date? Source is MEPRS Manager

Number of Timecards Submitted On-time

Total Number of Timecards for an MTF

d) For DMHRSi, what is the percentage of approved timecards by the suspense date? Source is MEPRS Manager

Number of Timecards Approved On-time

Total Number of Timecards for an MTF

Data Quality StatementValidation and Reconciliation


Data Quality Statement Compliance

Question 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).*

a) MEPRS/EAS (45 days) Source is MEPRS Manager/MEWACS

b) SIDR/CHCS (5th Duty of Day of the month) Source is BDQAS

c) WWR/CHCS (10th Calendar Day Following Month) Source is BDQAS

d) SADR/ADM (Daily) Source is BDQAS


Data Quality Statement Rounds Compliance

One calendar day of the attending professional services during each audited hospitalization will be audited from the randomly selected sample. For one day hospitalizations, that calendar day

will be audited. For all other hospitalizations, the registration

number will determine which calendar day will be audited. Odd numbers will use the first dayEven numbers will use the second day


Data Quality Statement Coding Accuracy Calculation

Use the following formulas for Q5b-d (Internal Process), 6b-d (Audit Tool), 7b-c (Audit Tool):

ICD-9: Number of correct ICD-9 codes

Total number of ICD-9 codes

E&M: Number of correct E&M codes

Total number of E&M codes

CPT: Number of correct CPT codes

Total number of CPT codes


Question 5. Outcome of monthly inpatient coding audit

a) Percentage of inpatient records whose assigned DRG codes were correct?

b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?

c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?

d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?

Data Quality Statement Compliance


Question 5. Inpatient Records. CONT… e) What percentage of completed and current (signed

within the past 12 months) DD Forms 2569 (TPC Insurance Info) are available for audit? (How the patient answered is only relevant to answering “Question 6f”)

The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program.

Options for filing DD Form 2569: Maintain hardcopy DD Form 2569 in medical record Scan DD Form 2569 and store electronically Hardcopy DD Form 2569 stored in the MTF RMO/Business/TPC

Office

Data Quality Statement Availability/Accuracy


Question 5. Inpatient Records. CONT…

f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

Internal Process based on Question 6e. Does not apply to OCONUS bases.



Question 6. Outpatient Records a) Is the documentation of the encounter selected to be

audited available? Documentation includes documentation in the medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA. (Denominator equals sample size.)

b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.)

c) What is the percentage of ICD-9 codes deemed correct? d) What is the percentage of CPT codes deemed correct?

(CPT code must comply with current DoD guidance.)

Source for a, b, c, d is Audit Tool



Question 6. Outpatient Records. CONT…

e) What percentage of completed and current (signed within the past 12 months) DD Forms 2569s (TPC Insurance Info) are available for audit?

Audit Tool Generated/Internal Process (This metric only measures whether or not a DD Form 2569 was collected/current in the record at the time of the encounter).

The DD Forms 2569 need to be available and current at the time of the audit to be in compliance with the UBO program.

f) What percentage of available, current and complete DD Forms 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

Internal Process based on Question 6e. Does not apply to OCONUS bases.



Question 7. Ambulatory Procedure Visits (C.7.a,b,c,d,e)

Questions 7.a,b,c,d,e Are the same as Questions 6.a,c,d,e,f



Question 8. Comparison of reported workload data.

a) # SADR Encounters (count only) / # WWR visits Source is BDQAS

b) # SIDR Dispositions / # WWR Dispositions Source is BDQAS

c) # EAS Visits / # WWR Visits Source is BDQAS

d) # EAS Dispositions / # WWR Dispositions Source is BDQAS

e) # of Inpatient Professional Services Rounds SADR encounters (FCC=A***)/#Sum WWR (Total Bed Days + Total Dispositions) Note: FY10 Goal is 80% (Will be graded red and green only)

Source is Monthly Statistical Report (Internal Process)

Data Quality Statement Completeness


Question 9. System Design, Development, Operations, and Education/Training (E.4.a).

a. # of AHLTA SADR encounters / # of Total SADR encounters (ALL SADR encounters including APV and ER)

Source is BDQAS

Note: This question is to gauge the penetration of AHLTA at our MTFs. It is understood that not all clinical modules are deployed in the current version of AHLTA.

Data Quality Statement AHLTA Penetration


Question 10. CHCS software used during the reporting month to identify duplicate patient registration records. (C.2a)

a) What was the number of potential duplicate records in the reporting month? (NOTE: Only Host sites report up.) Source is Internal Process

Run the CHCS standard report – “Potential Duplicate Patient Search”.

Data Quality Statement AHLTA Penetration


Question 11. I am aware of data quality issues identified by the completed DQ Statement and DQMC Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. (Electronic Signature Authorized)

Data Quality Statement Awareness


Take Away

DQ is not just the DQ statement.

Data needs to be accurate, complete and timely.

Front-end processes are CRITICAL to back-end success


Important References

DODI 6015.1-M, DOD Glossary DODI 6010.13M, MEPRS Program for Fixed MTFs and DTFs DODI 6010.15M, Uniform Business Office DODI 6040.40, Data Quality Program DODI 6040.41, Medical Records Retention and Coding at MTF DODI, 6040.42, Medical Encounter and Coding at MTF DODI, 6040.43, Custody and Control of Medical Records AFI 41-102, AF MEPRS Program for Fixed MTFs and DTFs AFI 41-120, Resource Management Operations AFI 41-210, Patient Administration Functions DoD Professional Coding Guidelines AF Workload Standardization Guidelines EASIV Reference Guide


Useful Web Sites Data Quality

http://www.tricare.mil/ocfo/mcfs/dqmcp/management_control.cfm BDQAS - https://bdqas.brooks.af.mil/index2.htm UBU - http://www.tricare.mil//ocfo/bea/ubu/index.cfm UBO - http://www.tricare.mil/ocfo/mcfs/ubo/about.cfm MEPRS – http://meprs.info DMHRSi - https://dmhrsi.satx.disa.mil

https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=DMHRS1 MEWACS - http://www.meprs.info/mol3/mol3.cfm DFAS - https://mypay.dfas.mil/mypay.aspx HIPAA - http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm SAIC - http://www.chcs-dm.com/


QUESTIONS?